Patient and Family Learning Centre Information Request Form

Patient and Family Learning CentreInformation Request FormRequestor Information: (Please print clearly)Date of Request:Date needed by (if possible):First Name:Last Name:Telephone:You are a :PatientFamily member / friendStaffOtherHow will the information be picked up:Patient and Family Learning CentreEmail (fill in email address below)Email AddressMail (fill in details below for this request)AddressCity Province Postal CodeFormat of information:There is a small collection of multi-media resources. If you have a preference for who you like to get information we will try tomatch your request.How do you like to learn and receive information? (Check all that apply)Reading / printed materialSeeing / pictures and illustrationsHearing / CD's, DVD'sDoing / an interactive game or something to practice

Search information details:Topic / Search Question:Keywords: (check all that apply)Stage Prevention Tests / Diagnosis Treatments / DrugsCausesSupport ServicesSelf Management / CareSide EffectsSymptomsAlternative MedicinesDescribe the details of therequestWhat language would you like to receive your request in?There is a small collection of multi-lingual resources available. We will try our best to meet your needs as requested.Language RequestedIt is OK for the Librarian to contact me by email address or phone number if he/she needs more details for my search.YesNo